ASSESSMENT OF AV FISTULA

AV access types
Fistula: Formed by subcutaneous anastomosis of an artery to an adjacent vein, allowing flow directly from artery to vein. Graft : a tube made of prosthetic material bridges the gap between the feeding artery and vein

AV fistula over Grafts : Why?

Lesser stenosis rates. Lesser infection rates. Simple surgical procedure, done on OPD basis. Thus avoiding/ markedly reducing hospitalization and emergency operations for complications

Comparison of graft and fistula outcomes in HD patients

Comparison of graft and fistula outcomes in HD patients

GUIDELINES

KDOQI, & Fistula First initiative: Targeting 60 % use of AV fistulas in patients beginning on HD, and 50 % fistula use in prevalent patients.

HURDLES: Fistula Hurdle

Hurdles OVERCOME by:

Early referral to nephrologist Early access evaluation and construction of access avoid central vein cannulation. Use of preop imaging of arterial & venous system to maximize successful creation of functioning fistula Dedicated and trained vascular surgeon as part of vascular access team.

ANTICIPATE NEED FOR AV access.

In pts with progressive renal failure protect the veins minimize venipunctures and catheter placement in forearm veins. Avoid subclavian vein catherterization. Avoid PICC.
Create AVF atleast 6 months prior to initiating HD.

EVALUATION
Preop evaluation For Maturation For complication

EVALUATION
PREOP Evaluation: history physical examination imaging studies.

Pt HISTORY
Dominant arm: To minimize negative impact on quality of life, use of the nondominant arm is preferred. History of previous central venous catheter, History of pacemaker use : associated with central venous stenosis

Pt HISTORY

History of severe congestive heart failure: Accesses may alter hemodynamics and cardiac output. History of arterial or venous peripheral catheter: Previous placement of an arterial or venous peripheral catheter may have damaged target vasculature History of diabetes mellitus: Diabetes mellitus is associated with damage to vasculature necessary for internal accesses.

Pt HISTORY

History of anticoagulant therapy or any coagulation disorder: Abnormal coagulation may cause clotting or problems with hemostasis of accesses. Presence of comorbid conditions, such as malignancy or coronary artery disease, that limit patients life expectancy. Morbidity associated with placement and maintenance of certain accesses may not justify their use in some patients. History of vascular access: Previously failed vascular accesses will limit available sites for accesses.

EXAMINATION
Bp, arm girth, Allens test in both arms. Arm edema, presence of collterals, differential exterimity size central vein stenosis. Look for evidence of central or venous catheterization, trauma to arm, chest neck.

Imaging studies
Routinely used To select appropriate vessel and location

Imaging studies
Doppler ultrasonography Venography Arteriography Magnetic resonance

DOPPLER ULTRASONOGRAPHY

To check arterial inflow. To assess venous anatomy and patency prior to AV fistula formation or graft insertion. To identify the presence of cephalic vein branches needing ligation to prevent diversion of flow from the fistula. To study subclavian vein patency as stenosis there leads to early failure of the fistula

DOPPLER ULTRASONOGRAPHY

SIZE: lumen diameter: feeding artery 2 mm target vein 2.5 mm NORMAL VEIN : lumen is echo free. thin wall. Wall thickening pathology. valves may be seen comprssible with min external pressure.

DOPPLER ULTRASONOGRAPHY

VEIN DILATION TEST: 50% increase in internal diameter of vein after proximal occlusion is associated with a good fistula outcome.

DOPPLER ULTRASONOGRAPHY

ARTERIAL DILATION TEST: Pulse contour of artery is normally triphasic. Clench fist for 2 mins and then open it during hyperemic phase the pulse contour will be biphasic - adequate arterial dilatation.

VENOGRAHY: Indications
Extremity edema Presence of collaterals Differential extremity size Current or previous subclavian catheter placement of any type in venous drainage of planned access

VENOGRAHY: Indications
Current or previous transvenous pacemaker in venous drainage of planned access Previous arm, neck, or chest trauma or surgery in venous drainage of planned access Multiple previous accesses in an extremity planned as an access site

Arteriography: indications
Diminished pulses in desired extremity BP difference of > 20 mm Hg between arms.

Assessment of the New AVF for Maturity

Fistula Maturation

Definition: Process by which a fistula becomes suitable for cannulation (ie, develops adequate flow, wall thickness, and diameter) Rule of 6s: In general, a mature fistula should:
Be

a minimum of 6 mm in diameter with discernible margins when a tourniquet is in place Be less than 6 mm deep Have a blood flow greater than 600 mL/min Be evaluated for nonmaturation 46 weeks after surgical creation if it does not meet the above criteria
National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.

During AVF Maturation Process

Look, listen, and feel the new AVF at every dialysis treatment After the scar heals, begin assessing AVF using a gentle tourniquet placed high in the axilla area Instruct patient to start access exercises after healing (check with surgeon first) Document patient education as well as condition and maturation of the AVF

Maturing Fistula
Vessel diameter must be 46 mm Vessel walls should toughen and be firm to the touch There should be no prominent collateral veins

During Maturation
Feel for strong thrill at arterial anastomosis Listen for continuous low-pitched bruit

During Physical Examination

Assess AVF for complications

Thrombosis Stenosis

Infection
Steal

syndrome Aneurysms

Select cannulation sites

Fistula Maturation

What diagnostic tools or techniques can be used to determine if an AVF is ready for cannulation?

Diagnostic Tools/Techniques to Determine If an AVF Is Ready

Duplex Doppler study Physical exam by the:

Nephrologist Nephrology Surgeon

nurse

Angiogram (fistulogram)

Best Tool/Technique?
Physical Exam!
Look, Listen, and Feel Use Your: Eyes

Ears
Fingertips

Assessment of the AVF for Complications

Look for Complications

Changes in Access Redness

Drainage Abscess Cannulation sites Aneurysms

Infection

Changes in Access Extremity Skin color Edema Small blue or purple veins Hematoma Bruising

Central or outflow vein stenosis

Distal Areas of Access Extremity Hands/Feet: Cold Painful Steal Numb syndrome Fingers/Toes: Discolored

Stenosis

Harbinger of thrombosis. Reduces blood flow rate underdialysis. Cause: fibrosis following needle stick injuries, abscess, pseudoaneurysm.

Stenosis

Observe Access Extremity for Stenosis

Before the patient has needles inserted

Make

a fist with access arm dependent; observe vein filling Raise access arm; entire AVF should flatten/ collapse if no stenosis/obstruction

If a segment of the AVF has not collapsed, stenosis is located at junction between collapsed and noncollapsed segment Instruct patient to perform this at home

Stenosis

An increase in the intensity of the thrill, or the pitch of the bruit as one moves the finger/ stethescope along the midportion of the draining vein implies stenosis.

Other methods of predicting stenosis: MEAURING ACCESS FLOW

DIRECT: Indicator dilution method Doppler MRA INDIRECT: serial measurement of intra access pressure.

Access flow measurements.

Flow through AV fistula averages 500-800 ml per min. KDOQI reccomends to intervene if flow rate is < 600 ml/min, or there is decrease in flow rate by > 25% over the preceding 4 months.

INTERVENTION FOR STENOSIS

PTCA or revision surgery in a pt with > 50% stenosis with 1 or more of following: abnormal physical examination previous h/o thrombosis decreasing access flow. elevated or increasing intra access presure.

Ischemia in a limb bearing AV acess

Ischemia distal to AVF can occur any time. Incidence 2-5 % Common in : DM, elderly, H/o CAD/PAD. Arm fistulas.

Vascular AccessInduced Ischemia

C/F: numbness, tingling, pain, motor weakness Signs: changes in skin color, temperature, loss of sensation, loss of motor fumction, or loss of distal arterial pulses, and development of arm edema when compared to other side.

Vascular AccessInduced Ischemia

Grade 1: pale/blue or cold hand without pain Grade 2: pain during exercise or HD Grade 3: ischemic pain at rest Grade 4: ulceration, necrosis, and gangrene

DIAGNOSING ISCHEMIA
Physical examination alone is inadequate. Additional noninvasive testing with measurement of digital pressures and calculation of the digit to brachial index, transcutaneous oximetry, ultrasound of forearm arteries, and access blood flow measurement are important steps in the diagnosis and decision-making process.

contrast angiography with visualization of the upper extremity arterial tree from the proximal subclavian artery to the distal palmar arches with and without AV fistula compression to enhance distal flow is obligatory to outline the strategy for treatment and to determine whether interventional or surgical options are preferred.

TO CONCLUDE:

Vascular access created with minimal delay. Have a functional fistula prior to initiate HD. Minimize CV catheter usage. A multidisciplinary approach to access creation and maintenance, involving nephrologists, interventional radiologists, access surgeons, and dialysis nurses, is mandatory to meet the burden of HD vascular access on health care facilities and costs

THANK YOU

REFERENCES

Dialysis access: current practice Comprehensive Clinical Nephrology Hand Book of Dialysis Current Management of Vascular Access: Review article-Clin J Am Soc Nephrol 2: 786800, 2007. KDOQI 2006 guidelines Fistula first initiative guidelines.